New Guidelines for Lightning Injury Prevention, Treatment

Laurie Barclay, MD

August 30, 2012

August 30, 2012 — The Wilderness Medical Society has updated their 2006 evidence-based practice guidelines describing precautions that can reduce risk for lightning injury, as well as effective medical treatments for lightning-related injuries. The updated recommendations, which aim to inform clinicians regarding best practices, appear in the September issue of Wilderness and Environmental Medicine.

"Lightning occurs nearly 50 times per second worldwide," write Chris Davis, MD, wilderness fellow and clinical instructor at the Department of Emergency Medicine, University of Colorado Hospital, Aurora, and colleagues. "Approximately one fifth of these flashes result in ground strikes. Internationally, an estimated 24,000 fatalities with 10 times as many injuries occur annually as a result of lightning."

The expert panel, which reviewed the available evidence concerning the prevention and treatment of lightning injury, primarily found small, retrospective case reports or series. Because prospective research regarding lightning injury is neither feasible nor ethical, this is hardly surprising.

In the United States, lightning-related fatalities have declined consistently during the past 5 decades to about 40 per year. Most of these deaths occur in men aged 20 to 45 years.

"With some basic prevention strategies and common sense the vast majority of lightning injuries can be prevented," Dr. Davis said in a news release.

Prevention Strategies

The expert panel convened by the Wilderness Medical Society strategies issued 5 stronger and 2 weaker recommendations for prevention, as classified using American College of Chest Physicians criteria. The guidelines recommend:

  • Individuals should find shelter when hearing thunder and should avoid bodies of water during lightning activity.

  • Individuals should delay resuming outdoor activity for at least 30 minutes after hearing the last thunderclap.

  • When lightning strikes are imminent, individuals should assume a sitting or crouching position with knees and feet close together, sitting on insulating material if available. If they are standing, their feet should touch, and if they are sitting, they should lift their feet off the ground.

  • To limit potential mass casualties, group members caught outdoors in a lightning storm should separate more than 20 feet from one another.

  • Commercial services can automatically notify subscribers when the National Lightning Detection Network detects nearby lightning.

  • In a mountain environment, peaks and ridgelines should be avoided in the afternoon

Treatment Strategies

Regarding treatment of lightning-related injuries, the committee included 18 specific recommendations. Especially noteworthy is a reverse triage recommendation for lightning strike victims, in which those lacking vital signs or spontaneous respirations receive top priority. The rationale is that simultaneous cardiac and respiratory arrest may result in sudden death from lightning strike, and that a second cardiac arrest may occur in many victims who have return of spontaneous circulation if ventilation is not supported.

Basic and advanced life support algorithms are the standard of care for lightning strike victims requiring resuscitation.

Patients incurring a direct strike, those with chest pain or shortness of breath, and other high-risk patients should undergo a screening electrocardiogram and echocardiography.

Long-term neurorehabilitation is often the only available treatment option for patients with permanent neurologic disability caused by lightning strikes.

The updated guidelines also discuss lightning-related injuries to the skin, eye, or ear, as well as considerations regarding psychiatric and neurocognitive function, pregnancy, disposition, and evacuation.

"Although the strength of the overall evidence is limited, the authors believe that many recommendations can be strongly supported as there is little risk of associated harm," the authors conclude. "Improved reporting to a national or international database could help with future epidemiological studies. Consensus on injury classification systems would also simplify the reporting process and allow data to be more easily combined for future study."

The authors have disclosed no relevant financial relationships.

Wilderness Environ Med. 2012;23:260-269. Full text


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